Core IM | Internal Medicine Podcast #189 Bisphosphonates and Fracture Prevention Trial: Beyond Journal Club with NEJM Group
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Oct 1, 2025 Discover who really faces fracture risks and why most fragility fractures occur in those without osteoporosis. Explore the surprising potential of just one or two IV infusions of zoledronate to prevent fractures for years. Examine the evolution of bisphosphonates in treatment and current debates over their risks. Delve into alternative options like teriparatide and learn about a significant trial showing promising results in a low-risk group. Finally, rethink how to discuss fracture prevention with patients and the public health implications of these findings.
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Many Fractures Occur Without Osteoporosis
- More than half of fragility fractures occur in people without osteoporosis by DEXA criteria.
- Relying on T-scores alone misses many at-risk patients who later sustain fractures.
Combine Risk Tools Not Just T-Scores
- Use DEXA T-scores, fragility-fracture history, and FRAX together when assessing fracture risk.
- Consider treatment when FRAX predicts high 10-year fracture risk even if T-score isn't osteoporotic.
From Weekly Pills To Yearly IV
- Bisphosphonates evolved from oral alendronate to yearly IV zoledronate, improving adherence.
- Zoledronate showed large reductions in clinically meaningful vertebral fractures in HORIZON.